Delays in Speech and Language Development PDF

4/22/2020 Rudolph's Pediatrics, 23e Chapter 89: Delays in Speech/Language or Nonverbal Development and Learning Disabilities Sonia Monteiro; Noel Mensah-Bonsu INTRODUCTION Language and nonverbal/visual-motor problem solving are components of the neurocognitive stream of development. Because the...

4/22/2020 Rudolph's Pediatrics, 23e Chapter 89: Delays in Speech/Language or Nonverbal Development and Learning Disabilities Sonia Monteiro; Noel Mensah-Bonsu INTRODUCTION Language and nonverbal/visual-motor problem solving are components of the neurocognitive stream of development. Because the most common causes of neurodevelopmental disability a ect the brain di usely (eg, genetic disorders), delays in language development are most commonly accompanied by delays in nonverbal/visual-motor problem-solving development and vice versa. Thus, the most prevalent mild neurodevelopmental di iculty that results in school failure is “slower learning,” where both language and nonverbal/visual-motor problem solving are delayed, resulting in intelligence quotients in the borderline (IQ = 70–79) to low average (IQ = 80–89) range. The globally delayed pattern of slower learning occurs in 22.8% of the population, while the dissociated pattern of learning disabilities occurs in only approximately 5% to 10% of the population. In the dissociated pattern of learning disabilities, there is a discrepancy between cognitive abilities and academic achievement, typically with discrepant or dissociated delays in language relative to nonverbal/visual-motor problem-solving development (as observed in language-based learning disabilities) or discrepant or dissociated delays in nonverbal/visual-motor problem solving relative to language development (as observed in nonverbal learning disabilities). It is also important to note that inadequate academic instruction is a common cause of learning problems. This chapter will review the spectrum of dissociated delays in language and nonverbal/visual-motor problem-solving development, including specific language-based and nonverbal learning disabilities. DEFINITIONS OF SPEECH AND LANGUAGE Language is defined as a method of both spoken and written communication. Language is made up of multiple components: phonology, morphology, syntax, semantics, and pragmatics. Phonology involves speech sounds (phonemes) that make up words, and morphology involves the units of language (morphemes) that make up words. Syntax is defined as the rules regarding how words can be combined into sentences, including verb tense, word order, and sentence structure. Semantics is defined as the meaning of words in context or when combined into sentences. Pragmatics is defined as the rules for social communication. Language is separated into expressive and receptive components. Expressive language refers to what a child is able to communicate verbally or through the use of signs or gestures. Receptive language refers to what a child is able to understand. 1/13 4/22/2020 Speech includes the following components: articulation, fluency, and voice. Articulation involves the production of speech sounds and a ects the intelligibility of speech. Fluency refers to the flow of sounds, syllables, and words together to form sentences. Voice includes the anatomical function of the vocal folds as well as airflow to produce sounds. SPEECH AND LANGUAGE DEVELOPMENT Speech and language development can be divided into 3 periods during early childhood (birth to 2 years of age). The first is the prespeech period, which begins at birth. In the first few months of life, an infant will typically progress from alerting to sound to responding to and seeking familiar voices. An infant’s cry will start to di erentiate based on his or her needs. Cooing (the production of vowel sounds) occurs at around 3 months of age. The infant will begin to combine vowel sounds at around 5 months of age. This will be followed by the production of single consonant sounds, and by 6 months of age, vowel and consonant sounds will be combined together in the form of babbling. By 9 months of age, gestures including reaching to be picked up and waving “bye-bye” emerge. The second period, known as the naming period, occurs between 10 and 18 months of age. It begins with the ability to identify caregivers and objects by name, and this ability progresses to the verbal expression of single words. Prior to 1 year of age, most children begin to use a specific “Mama” and “Dada” as their first words, and by 1 year of age, 1 or 2 additional single words will be used. Most children will start to comprehend words frequently used by caregivers (eg, “bath,” “bottle”) and will start to follow simple gestured commands by 12 months of age. By 14 months of age, a child may combine sounds or mimic conversational sounds with varying intonation in the form of immature jargon. By 18 months of age, a child may begin to mimic words that they hear (echolalia). Also by 18 months of age, a child should have a vocabulary of about 10 words. Gestures progress during this period with the emergence of pointing. By 12 months of age, a child will start pointing to indicate a want or need (protoimperative pointing), and by 14 months of age, the child will start pointing to obtain the attention of an adult to share something of interest (protodeclarative pointing). Between 18 and 24 months of age, children will experience a dramatic increase in vocabulary, both receptively and expressively, which marks the word combination period. Total expressive language can include up to 50 to 100 words by the end of this period, and a child’s receptive vocabulary is usually larger. Also by the end of this period, a child should be combining words into 2-word sentences. From a receptive language standpoint, by 18 months of age, children will also begin to identify body parts and point to pictures when named. By 2 years of age, a child’s speech articulation should be at least 50% intelligible to others. By 30 months of age, echolalia should cease, children should be using pronouns appropriately, and they should be able to distinguish just 1 item from a greater number. By 3 years of age, a child should communicate in 3-word sentences, and their speech articulation should be 75% intelligible. Receptively, a 3year-old child should be able to follow 2-step directions including prepositions and pay attention for longer 2/13 4/22/2020 periods of time when read to. At 3 years of age, children may begin to ask “what” and “where” questions. By 4 years of age, speech should be completely (100%) intelligible. A child at 4 years of age should be able to relate experiences verbally using complex syntax and speak fluently. Red flags for speech and language delay are shown in Table 89-1. TABLE 89-1 RED FLAGS FOR SPEECH AND LANGUAGE DELAYa Age Receptive Language Expressive Language 12 mo Does not respond to name; does Does not babble not gesture (wave, point) 16 mo 18 mo Does not use single words Cannot follow simple Does not use at least 8–10 words commands (“give me,” “come here”) 24 mo Does not follow a 2-step Does not use any 2-word combinations; speech is not at least direction; cannot point to a 50% intelligible picture 30 mo 36 mo Continues to use echolalia; continues to confuse pronouns Cannot answer Does not use 3- to 4-word sentences; speech is not 75% “who/what/where” questions intelligible; leaves beginning or ending sounds o words aLoss of speech, babbling, or social skills is a red flag at any age. PEDIATRIC ASSESSMENT OF SPEECH AND LANGUAGE Speech and language milestones should be regularly assessed as part of routine developmental surveillance at every well child visit. Surveillance involves asking parents questions and documenting their responses regarding attainment of speech and language milestones, reviewing risk factors (including prematurity, previous concerns on prior evaluation, or concerns about appropriate environmental language stimulation). Parental concerns should be elicited and taken seriously. Surveillance also involves the provider’s direct observation of the child’s speech and language skills in the o ice visit. 3/13 4/22/2020 Standardized screening tests, such as the Ages and Stages Questionnaire (ASQ) and Parents’ Evaluation of Developmental Status (PEDS), are commonly used developmental screeners that assess multiple areas of development, including speech and language, and identify children who require further evaluation. Standardized screening tests should be regularly implemented at the 9-month, 18-month, and 24- or 30month well child visits. Parents of older children should be asked if their child has any di iculty with verbal expression or with following directions. Once a concern is identified (either through screening or surveillance), a referral for a speech and language evaluation should be made. This can be performed through early intervention or early childhood special education programs or by a private speech/language pathologist. In addition to referral for a speech and language evaluation, an audiology evaluation needs to be completed for every child with delayed speech and language skills to rule out hearing loss. Finally, it is important to note that boys with Klinefelter syndrome (XXY) tend to present with language disorders and language-based learning disabilities. The di erential diagnosis for a child presenting with concerns about delayed speech and language development includes language disorder, speech disorder, speech and language disorder, inadequate environmental stimulation, global developmental delay, social communication disorder, autism spectrum disorder, and hearing loss. PROMOTION OF LANGUAGE DEVELOPMENT Developmental milestones in language cannot be attained without appropriate language stimulation in the environment. Previous research has emphasized the importance of exposing children to language from an early age. Parents are encouraged to speak frequently to their infants and describe what is going on around them. It is also critical that parents read to and share books with their children starting in infancy. It has been established that the number of words that children are exposed to can vary significantly based on socioeconomic factors. Children from lower-income homes hear far fewer words than children in middle- or high-income settings. In addition to these gaps, the quality of parent–child interaction in language development, regardless of socioeconomic status, is critically important to language development. Parents should respond to their infants’ sounds and attempts at communication to encourage progression in language development. As their children become older, parents should be encouraged to have frequent conversations with their children. SPECTRUM OF DISSOCIATED SPEECH DELAY: SPEECH DISORDERS Dissociated delays in speech development are defined as speech disorders. Speech disorders involve di iculties with sounds required in the production of speech and include voice disorder, speech fluency disorder, phonologic disorder, apraxia of speech, and dysarthria. Voice Disorder 4/13 4/22/2020 Deficits in pitch, loudness, or vocal quality define a voice disorder. There may also be a hyper- or hyponasal quality to speech that may be secondary to anatomical di erences (such as velopharyngeal insu iciency or adenoid hypertrophy). Fluency Disorder In children with fluency disorders, the flow of speech is interrupted secondary to repetition of sounds or words and changes in the rate or rhythm of speech. Children between the ages of 2 and 3 years may have pauses, sound prolongations, or may repeat parts of words. This is considered to be a normal stage of language development and may be secondary to the dramatic increase in speech production during this time period. Usually these problems resolve without intervention by 4 years of age. If the dysfluency continues, stuttering is more likely, and referral for evaluation and treatment is indicated. Phonologic Disorder Many children will make errors in pronunciation when using new words. Each speech sound has an age by which it should be mastered, and errors in the production or pattern of these sounds result in speech articulation that is di icult to understand. Simple consonant sounds (/b/, /p/, /m/) as well as all vowel sounds are usually mastered by 2 years of age. More complex consonant sounds (/j/, /r/, /s/) as well as blends (/ch/, /sh/) are mastered later on. Children should be able to produce all sounds in the English language by 8 years of age. Childhood Apraxia of Speech Childhood apraxia of speech (CAS) is thought to be secondary to deficits in central nervous system mechanisms involved in organizing the motor movements necessary for the production of speech. It is not secondary to muscle weakness or paralysis. Children with CAS have di iculties with spontaneous production of sounds, syllables, and words. Most have a history of delayed cooing or babbling during infancy and delayed production of first words. Compared to children with a phonologic disorder who make consistent errors in speech production, children with CAS have irregular and inconsistent speech production. Dysarthria Dysarthria is a motor disorder that is the result of impairment of muscles used in speech production. Muscles may be weak or paralyzed, or there may be problems with coordination. This limits jaw, lip, and tongue movement, resulting in a slow rate of speech, poor articulation, change in voice quality or pitch, and speech that sounds “mumbled” or “slurred.” Dysarthria is most commonly observed in children with cerebral palsy (CP). SPECTRUM OF DISSOCIATED LANGUAGE DELAY 5/13 4/22/2020 When children exhibit discrepant delays in their language development relative to their development in other developmental streams, they are described as exhibiting a dissociation in their language development. Of all the streams of development, the language stream is the best single predictor of cognitive potential. In addition, the ability to express and understand language has an impact on social functioning. Language ability predicts school readiness, and deficits in early language development are directly correlated to future language-based learning disabilities and decreased academic achievement. Language Disorders (Specific Language Impairment) A language delay occurs when the progression of language development is occurring in the correct sequence, but at a rate slower than typical. Language delays occur more frequently in boys and when there is an established family history of language delay, speech/language disorders, or language-based learning disabilities. Additional risk factors include prematurity, lack of appropriate developmental stimulation, and lower socioeconomic status. Language delays should not be attributed to birth order (having siblings who “speak for” the child) or to the child being exposed to multiple languages. By 4 years of age, many children with a history of speech and language delays, especially those who have experienced a lack of appropriate language stimulation before receiving appropriate early intervention and early childhood special education services, will “catch up” and not have persistent language di iculties. However, many children will continue to exhibit persistent language delays. Preschool-aged children with dissociated delays in their language development currently meet DSM-5 criteria for a diagnosis of language disorder. However, children with persistent language delays as they enter school are at significant risk for developing language-based learning disabilities. Children with a language disorder, also known as a specific language impairment, struggle to use language to express themselves and have di iculties understanding the messages of others. Children with language disorders can have discrepant delays in all or just 1 of the components of language (phonology, morphology, syntax, semantics, and pragmatics). These problems with language development are not secondary to hearing loss or to a language delay that is observed as a component of a global developmental delay. Children with language disorders by definition are not globally delayed, and most have typical nonverbal abilities, adaptive functioning, and social skills. Children with language disorders may initially present with a chief complaint of “delayed speech.” However, once they start to use words, they may continue to struggle with following directions, being able to form sentences or use verb tenses correctly, or having a conversation. Language disorders can involve both receptive and expressive language or just expressive language. They cannot involve only receptive language with spared expressive language, as a child can never express what he or she does not understand. A child with a receptive language disorder will have di iculty with understanding what is said and with following directions. Children with an expressive language disorder present with problems expressing their thoughts or needs. Their sentences may be shorter and less complex than what would be expected for their age or developmental level. They may mix up the order of words in sentences, leave words out, or make errors in verb tense. Most children with language disorders will have deficits in both expressive and receptive language. Children with a language disorder are at increased risk of 6/13 4/22/2020 language-based learning di iculties, even those children who appeared to have progressed to having typical spoken language. Children with both speech and language disorders are also at increased risk of emotional and behavioral problems. LANGUAGE-BASED LEARNING DISABILITIES Definitions of Learning Disability A learning disability (LD) has been classically defined as an unexpected discrepancy in academic performance compared to intellectual potential; however, this definition has been challenged and remains controversial. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) characterizes “specific learning disorders” as being evidenced by academic skills that are substantially and quantifiably below those expected for an individual’s chronologic age, which have persisted for at least 6 months despite the provision of targeted interventions, and that are not due to intellectual disability, uncorrected vision or hearing deficits, other mental or neurological disorders, psychosocial adversity, lack of proficiency in the language of academic instruction, or inadequate academic instruction. Thus, children with specific learning disorders must now show a lack of response to intervention before being considered to have a learning disability by many school districts. Previously, most children with slower learning (IQs between 70 and 90), who o en struggled to keep up with average and above-average peers in regular classroom placements, did not qualify for any special education services. This is because the majority of children with slower learning, despite having academic achievement scores that are below grade level, have academic achievement abilities that are commensurate with their cognitive expectations, and thus show no discrepancy between cognitive abilities and academic achievement. However, the new DSM-5 definition qualifies students under the specific learning disorder diagnosis whose academic achievement is below that expected for chronologic age. Under this definition, a majority of children with slower learning may now qualify for special education services. Although these children do not have academic achievement that is below expected for their cognitive abilities, their academic achievement is certainly below that expected for their chronologic age. Hopefully, this change in definition will provide children who learn more slowly the same remedial special education services received by children with specific learning disabilities, particularly as research has shown these interventions to be e ective in improving academic outcomes no matter whether an individual has a discrepancy between cognitive abilities and academic achievement or not. Spectrum of Language-Based Learning Disabilities Children with preschool language disorders are at significant risk of developing language-based learning disabilities as they enter school. Children with language disorders can have discrepant delays in all or just 1 of the components of language (phonology, morphology, syntax, semantics, and pragmatics). Thus, the mild end of the spectrum of dissociated language delay would include discrepant delays in 1 component of language (eg, phonology), while the severe end would include discrepant delays in multiple components of receptive and expressive language, which is associated with discrepant verbal reasoning compared to nonverbal reasoning on IQ testing (Fig. 89-1). 7/13 4/22/2020 Figure 89-1 Spectrum of language dissociation. Thus, the mild end of a spectrum of dissociated language delay includes individuals with dissociated di iculties in phonology, resulting in phonological processing disorders (Fig. 89-1). Children with di iculty with phonology have trouble learning to associate written symbols with the sounds they make, leading to dysphonetic dyslexia. Children with dysphonetic dyslexia have trouble sounding out words, and thus, they have di iculty with reading decoding, reading fluency, and encoding (spelling). However, children with dysphonetic dyslexia have intact nonverbal abilities, and they can memorize sight words. This skill may allow a child with dysphonetic dyslexia to compensate early on at school, but their reading disability becomes more apparent in advancing grades, when the focus shi s from “learning to read” to “reading to learn.” In addition, despite their di iculties with phonology, children with dysphonetic dyslexia have otherwise intact language abilities. Thus, while they may not be able to obtain information through reading, they can understand and obtain information through being read to or through listening to books on tape. Similarly, while their di iculties with encoding negatively impact the written expression required of written reports, they can give oral reports without significant incident. As more components of receptive and expressive language become dissociated, one moves toward the more severe end of the spectrum of dissociated language delay, and children experience language-based learning disabilities. These more severe delays—which may di usely a ect phonology, morphology, syntax, and semantics—negatively impact verbal reasoning, and children with language-based learning disabilities typically exhibit verbal IQ scores that are dissociated from nonverbal IQ scores. Rather than simply a ecting reading decoding and encoding, language-based learning disabilities result in di iculties in reading 8/13 4/22/2020 comprehension, math word problems, written expression, listening comprehension, and oral expression. Children with language-based learning disabilities would have similar di iculties with comprehension whether attempting to read themselves or when being read to or listening to books on tape. Children suspected of having dyslexia or language-based learning disabilities need to undergo a full and individual evaluation through their local public schools and be provided with direct language therapy services, remedial academic instruction, and maximal accommodations and modifications of all assignments, materials, texts, pacing, and grading when included in regular classroom settings. NONVERBAL/VISUAL-MOTOR PROBLEM-SOLVING DEVELOPMENT Nonverbal/visual-motor problem-solving development involves the development of visual perceptual, visual-spatial, and visual-motor skills. In the first 3 months of life, this domain of development focuses on visual tracking, as children should be able to visually track through 360 degrees by 3 months of age. As this domain of development matures, skills include reaching for and transferring objects at 5 months, using an immature pincer grasp to pick up pellet-sized objects by 9 months, uncovering hidden toys by 10 months, and intentionally releasing objects into containers by 12 months. A er 12 months, drawing and block construction skills emerge, with making a crayon mark at 12 months, scribbling spontaneously and stacking 3 blocks at 18 months, imitating a horizontal and vertical stroke and building a horizontal train of blocks at 24 months, and drawing a circle and building a 3-block bridge at age 3 years. Many adaptive skills also rely on nonverbal/visual-motor skill development, such as spoon feeding by 14 months, unzipping by 21 months, unbuttoning by 3 years, buttoning by 4 years, and tying shoes by 5 years. PEDIATRIC ASSESSMENT OF NONVERBAL/VISUAL-MOTOR PROBLEM SOLVING Nonverbal/visual-motor problem-solving milestones should be regularly assessed as part of routine developmental surveillance at every well child visit. It may be more di icult to obtain a developmental history of nonverbal/visual-motor problem-solving skill acquisition from families; for example, they may not have exposed their children to crayons or blocks. Thus, the nonverbal/visual-motor problem-solving developmental history may need to focus on activities of daily living that rely on visual-motor problemsolving skills, such as feeding and dressing. Fortunately, while it may be di icult to elicit a developmental history in this domain, nonverbal/visual-motor problem solving is the domain that is easiest to observe in the o ice, as the items used in this domain are fun for children to complete (drawing, building with blocks, completing puzzles). Standardized screening tests, such as the ASQ and PEDS, assess multiple areas of development, including nonverbal/visual-motor problem solving, and identify children who require further evaluation. Standardized screening tests should be regularly implemented at the 9-month, 18-month, and 24- or 30-month well child visit. Older children can be asked to draw pictures of a person or to provide a handwriting sample. 9/13 4/22/2020 Once a concern is identified (either through screening or surveillance), a referral for an occupational therapy evaluation should be made. This can be performed through early intervention or early childhood special education programs or by a private occupational therapist. In addition to referral for an occupational therapy evaluation, a vision screen or ophthalmology evaluation needs to be completed for every child with delayed nonverbal/visual-motor problem-solving skills to rule out a vision impairment. Finally, children with specific medical diagnoses appear at higher risk for nonverbal/visual-motor problem-solving disorders and nonverbal learning disabilities, including children with Turner syndrome (XO), hydrocephalus/spina bifida, and velocardiofacial syndrome (deletion of chromosome 22q11.2). SPECTRUM OF DISSOCIATED NONVERBAL/VISUAL-MOTOR PROBLEMSOLVING DEVELOPMENT Nonverbal/Visual-Motor Problem-Solving Disorders Children may exhibit dissociated delays in nonverbal problem solving in multiple domains, including visual discrimination, visual figure-ground discrimination, visual sequencing, visual-motor processing, visual memory, visual closure, and visual-spatial relationships. Children with nonverbal/visual-motor problemsolving disorders will evidence dissociated delays in the milestones reviewed above. School-aged children with these delays will have di iculty with drawing, writing, right/le orientation, and completing puzzles, and may get lost in familiar places. Spectrum of Nonverbal Learning Disabilities When children with persistent nonverbal/visual-motor problem-solving disorders enter school, they are at increased risk of developing nonverbal learning disabilities. At the mild end of the spectrum of nonverbal learning disabilities are children whose dissociated delays in nonverbal development involve primarily their orthographic processing (Fig. 89-2). Orthographic processing is the use of the visual system to form, store, and recall written letters and words and also involves using the visual system to process punctuation and capitalization. Children with orthographic processing deficits are at risk for developing dyseidetic dyslexia. Children with dyseidetic dyslexia have problems memorizing the pattern of letters (eg, they may confuse “b” and “d”) and di iculty memorizing sight words. Given their preserved phonological processing, children with dyseidetic dyslexia need to laboriously sound out the same word over and over, and they tend to misspell phonetically. Figure 89-2 Spectrum of nonverbal/visual-motor problem-solving dissociation. 10/13 4/22/2020 As more components of nonverbal/visual-motor problem solving become dissociated, one moves toward the more severe end of the spectrum of dissociated nonverbal/visual-motor problem-solving delay, and children experience nonverbal learning disabilities. These more severe delays, which may di usely a ect visual discrimination, visual figure-ground discrimination, visual sequencing, visual-motor processing, visual memory, visual closure, and visual-spatial relationships, negatively impact nonverbal reasoning, and children with nonverbal learning disabilities typically exhibit nonverbal IQ scores that are dissociated from verbal IQ scores. Rather than simply having di iculty with reading sight words, nonverbal learning disabilities result in di iculties in writing (dysgraphia), drawing, right/le discrimination, completing puzzles, math computation and processing (dyscalculia), geometry, geography, and getting lost in familiar places, and may involve understanding spatial relations, including social reasoning. (The most severe end of the spectrum of nonverbal dissociation + deviation includes the social communication disorder typically observed in children previously described as having Asperger disorder, but currently described as having autism spectrum disorder without a language disorder; see Chapter 83 and Chapter 91.) Children suspected of having dyseidetic dyslexia or nonverbal learning disabilities need to undergo a full and individual evaluation through their local schools and be provided with direct occupational therapy services, remedial academic instruction, and maximal accommodations and modifications of all assignments, materials, texts, pacing, and grading when included in regular classroom settings. COMORBIDITIES OF LEARNING DISABILITIES In the continuum of developmental-behavioral diagnoses, dissociated delays in 1 stream of development are o en associated with dissociated delays in other streams of development (see Chapter 83). Thus, children with the dissociated neurocognitive developmental profile of learning disabilities o en also have the dissociated neurobehavioral developmental profile of attention-deficit/hyperactivity disorder (ADHD) and 11/13 4/22/2020 the dissociated neuromotor developmental profile of speech articulation disorders, handwriting di iculties (dysgraphia), and gross motor incoordination (dyspraxia). Up to 50% of children with ADHD have comorbid learning disabilities in reading (dyslexia), math (dyscalculia), or written expression. Secondary social, emotional, or behavioral comorbidities are particularly concerning in children with learning disabilities. An unrecognized learning disability may result in school failure. Signs and symptoms of academic distress secondary to an unrecognized learning disability include increased time and e ort to complete classroom assignments, anxiety or avoidance of school, acting out, failing grades, or grade retention. It is critical for primary care pediatric medical providers to know that grade retention has not been found to improve a child’s educational outcome, and those who have been retained are more likely to have behavioral issues and to eventually drop out of school. Children who have been recognized by their schools to have learning disabilities require remedial special educational instruction in their areas of disability. However, just as importantly, they require maximal accommodations and modifications in order to be successfully included in regular classroom activities. Children with learning disabilities should not be expected to compete with similarly aged peers who do not share their specific learning disabilities in a regular classroom without maximal accommodations and modifications of all assignments, teaching materials, texts, testing, pacing, and grading. Children with learning disabilities should not be expected to attend to academic material that they do not understand or to complete assignments that are beyond their current level of ability. Maximal accommodations and modifications are required in order to ensure that demands and expectations for academic performance in the regular classroom are made commensurate with underlying abilities. Without such accommodations and modifications, demands for a child’s performance will exceed his or her abilities, and this could produce secondary anxiety and frustration and lead to social, emotional, or behavioral di iculties, including low self-esteem, low self-confidence, school negativity, social withdrawal, task-avoidant and passively resistant behaviors (secondary inattention), and potentially school dropout. Such a mismatch between demands and expectations and performance also can result in attention-seeking, oppositional, or acting-out behaviors (that can be misperceived as secondary impulsivity or hyperactivity), which can lead to detention or school suspension. The regular classroom teachers of children with learning disabilities need to work very closely with their schools’ learning disabilities specialists to ensure that maximal accommodations and modifications are being made in all regular classes. Examples of such accommodations and modifications may include being given extended time to complete shortened and maximally modified assignments, untimed tests, being provided audio textbooks or a calculator, and being allowed to give oral reports and oral answers to essay questions rather than written reports and essays. It is also very important for children with learning disabilities to participate in extracurricular activities that they enjoy, and in which they feel they are successful, in order to serve as a source of self-esteem building, socialization, and peer interaction. Extracurricular activities at school are particularly encouraged, so that school can remain a rewarding experience. SUGGESTED READINGS 12/13 4/22/2020 American Speech-Language-Hearing Association. Child speech and language. http://www.asha.org.ezproxy.fau.edu/public/speech/disorders/ChildSand. Accessed June 10, 2016. Accardo PJ, Capute AJ. The Capute Scales: Cognitive Adaptive Test/Clinical Linguistic & Auditory Milestone Scale (CAT/CLAMS) . Baltimore, MD: Paul H. Brookes Publishing Company; 2005. American Psychiatric Association. Specific learning disorder. In: Diagnostic and Statistical Manual of Mental Disorders , 5th edition. Arlington, VA: American Psychiatric Association; 2013:66–74. Centers for Disease Control and Prevention. Learn the signs. Act early. https://www-cdcgov.ezproxy.fau.edu/ncbddd/actearly/. Accessed June 10, 2016. Cortiella C, Horowitz SH. The State of Learning Disabilities: Facts, Trends and Emerging Issues . New York, NY: National Center for Learning Disabilities; 2014. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics . 2006;118(4):1808– 1809]. American Academy of Pediatrics Policy Statement. Pediatrics . 2006:118(1):405–420. Learning Disabilities Association of America Web site. https://ldaamerica.org. Accessed August 17, 2016. Macias MM, Twyman KA. Speech and language development and disorders. In: Voigt RG, Macias MM, Myers SM, eds. Developmental and Behavioral Pediatrics . Elk Grove Village, IL: American Academy of Pediatrics; 2010:201–219. Wallace I, Berkman N, Watson L, et al. Screening for speech and language delay in children 5 years old and younger: a systematic review. Pediatrics . 2015;136:e448–e462. [PubMed: 26152671] McGraw Hill Copyright © McGraw-Hill Education All rights reserved. Your IP address is 131.91.174.129 Terms of Use • Privacy Policy • Notice • Accessibility Access Provided by: Florida Atlantic University Silverchair 13/13